Integ - Neuropathic Ulcers

Question 1

what is a common characteristic of diabetic ulcer periwound?

Answer 1

callous around the wound bed

Question 2

characteristics of the neuropathic ulcer periwound

Answer 2

• callous
• thickened toenails
• edema, if autonomic neuropathy
• microvascular changes
• warm or cool

Question 3

when the body does not have enough glucose for energy, burns fats instead, resulting in a build up of acids

Answer 3

ketosis

Question 4

risk factors for T2 DM in childhood

Answer 4

> 85% body weight for age/sex
120% ideal weight
relative w DM
high risk ethnicity
mother w gestational DM

Question 5

how does DM relate to neuropathic ulcers

Answer 5

hyperglycemia -> more glucose -> more sorbitol made -> more damage

Question 6

how does high glucose lead to tissue damage

Answer 6

glucose will bind to proteins= glycosylated proteins
these cause tissue damage and form free radicals

Question 7

sorbitol results from what?

Answer 7

breakdown of glucose

Question 8

neuropathic ulcer risk factors

Answer 8

• vascular disease
• neuropathy
• mechanical stress
• impaired healing
• poor vision
• inadequate care and patient education!

Question 9

is neuropathic ulcers a micro or macro vascular disease?

Answer 9

microvascular- below the knee

Question 10

macrovascular diseases, with regards to ulcers, are usually where?

Answer 10

above the knee

Question 11

DM causing thickening of _________ ________, leading to decreased ___

Answer 11

thickening of basement membrane, decreased O2 and nutrients

Question 12

3 types of neuropathy

Answer 12

sensory, motor, autonomic

Question 13

what is the most common complication of DM T2

Answer 13

neuropathy

Question 14

neuropathy may be caused by _____ and or _____ dysfunction

Answer 14

neural ischemia ; segmental demyelination

Question 15

neuropathy tends to be

Answer 15

symmetrical affects distal areas first

note: increases with age and time since diagnosis

Question 16

inability to accurately perceive trauma to an affected area, usually no idea of loss

Answer 16

sensory neuropathy

Question 17

sensory neuropathy pts c/o of

Answer 17

paresthesias- burning, tingling, aching, stinging

Question 18

paralysis of the intrinsic muscles

Answer 18

motor neuropathy

Question 19

motor neuropathy in the feet:
___________ plantar pressure
_________ sheer forces
_________ stability in stance
hallux _______
claw toe deformity

Answer 19

increased plantar pressure
increased shear forces
decreased stability in stance
hallux valgus
claw toe deformity

Question 20

motor neuropathy in the hand:
__________ grip
_______ fine motor
_________ injury
hand deformity

Answer 20

decreased grip
decreased fine motor
increased injury hand deformity

Question 21

autonomic neuropathy skin changes

Answer 21

sweating mechanisms (decreased) , callus formation (increased) , disturbed blood flow

large contributor to neuropathic ulcers!

Question 22

what are systemic effects of autonomic neuropathy

Answer 22

tachycardia, excessive intolerance, hypotension, gastroparesis, sexual dysfunction

Question 23

what is diabetic neuropathic osteparthropathy due to

Answer 23

caused by peripheral neuropathy and autonomic neuropathy

Question 24

what leads to charcot foot?

Answer 24

shoving deformed foot into footwear that doesnt work anymore

uncontrolled vasodilation -> increased blood flow -> more Ca -> predisposed for fracture -> charcot foot

Question 25

will DM T2 patients always have an immune response with infection?

Answer 25

no

Question 26

hyperglycemia: ______ collagen synthesis, phagocytosis, angiogenesis, fibroblast proliferation ______ tensile strength

Answer 26

decrease collagen synthesis, phagocytosis, angiogenesis, fibroblast proliferation reduced tensile strength

Question 27

an ulcer that is larger, deeper, or older will take ____ to heal

Answer 27

longer

Question 28

midfoot ulcerations heal _______ than forefoot

Answer 28

midfoot ulceration heal faster than forefoot

Question 29

fasting glucose versus A1C

Answer 29

fasting- snapshot, fast for 12 hours beforehand A1C- aggregate of how they have managed glucose over the past 3 months.

Question 30

review (idk if this will be on the test)

Answer 30

Question 31

what are tests to assess circulation?

Answer 31

capillary refill, doppler US, ABI, TBI, arteriography, transcutaneous O2 measurement

Question 32

tests to assess sensory integrity

Answer 32

monofilament test 1st, 3rd, 5th digit 1st, 3rd, 5th met heads medial and lateral midfoot calcaneus test each 3 times

Question 33

for local neuropathic ulcer wound care, should the callus be removed?

Answer 33

yes- must be removed

Question 34

for local neuropathic ulcer wound care, do you moisturize in between toes?

Answer 34

no! you moisturize the periwound, but not between toes

Question 35

how do you protect the wound

Answer 35

with offloading devices

Question 36

wagner scale/ UT scale is for

Answer 36

grading neuropathic ulcers

Question 37

will calluses heal?

Answer 37

no

Question 38

what is the gold standard of care for neuropathic ulcers

Answer 38

total contact casting -TCC

Question 39

benefits of TCC

Answer 39

**off loads** ulcer by spreading pressure, helps with **edema management**, **decreased shear** and protects

Question 40

contraindications of TCC

Answer 40

non compliance, infection, edema fluctuations ABI <0.45

Question 41

what does gait and mobility help with for neuropathic ulcers?

Answer 41

mobilize while safely eliminate pressure on the ulcer

Question 42

patients who documented lack of protective sensation qualify for ___ pairs of DM shoes thru medicare each year

Answer 42

2

Question 43

___ can be used to improve ROM in joints with limited moblity

Answer 43

manual therapy

Question 44

what does ROM exercise help with neuropathic ulcers

Answer 44

limitations in ROM can increase pressure, addresses this issue

Question 45

aerobic exercise can help with what in neuropathic ulcers

Answer 45

glycemic control, help patient to understand ways to do this without walking

Question 46

good glycemic control can reduce DM complications: __% decrease in microvascular complications __% reduction in amputations

Answer 46

25% decrease in complications 36% reduction in amputations

Question 47

neuropathic ulcer treatment type 2 DM meds

Answer 47

oral hypogylcemics-sulfonylureas and biguanides

Question 48

neuropathy meds

Answer 48

gabapentin and antidepressants (anmitriptyline) , capsaicin, chili pepper extract, some prescribed opioids (not effective)

Question 49

arterial insufficency meds

Answer 49

dalteparin to improve local tissue oxygenation

Question 50

antibiotics meds

Answer 50

dur to increased risk of infection and decreased immune response, provide spectrum antimicrobial activity that penetrates into the involved area with few side effects, can be provided orally topically or IV

Question 51

surgeries for neuropathic ulcers

Answer 51

* surgical debridement * incision and drainage (abscesses) * address foot deformities (decrease pressure points) * amputation

Question 52

with infection there is a ___ x increased risk of amputation

Answer 52

154 x

Question 53

does medicare cover footwear?

Answer 53

yes- if patients have documented lack of protective sensation qualify for 2 pairs of DM shoes

Question 54

DFU CPG: recommendation I

Answer 54

PT and other health care providers who prescribe exercise for adults with a diabetic foot ulcer may **prescribe interventions to maintain CVD health and muscular fitness while minimizing WB on the foot. ** -**AD used as needed to improve balance and further reduce WB in an adult with a current diabetic foot ulcer ** | level D evidence

Question 55

DFU CPG Recommendation II

Answer 55

PT should measure physical fitness (flexibility, strength, Cardiorespiratory fitness, balance, motor agility) **(evidence C) **AND may measure level of PA such as step counting and standing, across the continuum of care of an adult with diabetes **(D)**

Question 56

DFU CPG: Recommendation IIIa

Answer 56

progressive moderate to vigorous-intensity exercise program including aerobic and resistance training to adults with diabetes after considering the pt's disease state and limits for exercise AND depending on pt physiologic response to exercise in accordance with pt's perference and resources (level A)

Question 57

DFU CPG: recommendation IIIb

Answer 57

PT who prescribe exercise may use activity montior - based counseling to increase PA | level B

Question 58

DFU CPG: recommendation IV

Answer 58

PT managing closed diabetes foot ulcers may tirate tissue reloading on a newly closed diabetic foot ulcer, maintaining mod to max offloading eps during the first 3 months and slowly titrating a return to shoe wear using a wear schedule | Level D

Question 59

DFU CPG: recommendation V

Answer 59

encourage aerboic exercise, strength training, and or PA for adults who have diabetes and can exercise safely to optimize long term QOL as well as reduce health care costs | level C